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' �'�• SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue,Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.orq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Pe t#: <br /> s M. PPA-T B Lv M Eck 00-75 2 `�Z 01 Date. <br /> Parameter/Standard —T—Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimjYe <br /> WD <br /> A❑ 11 <br /> Casing extends at least 12" above gradeA❑ <br /> Casing extends at least 1" above pedestal ❑ M' C At,4- C^.r• & <br /> Free of crackslcontiguous with-annular seal ❑ <br /> Graded to-allow drainage away from casing ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes ❑ No ❑ NA❑ - <br /> Seal between all pipe columns and casing Yes ❑ No ❑ NA❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ NA❑ <br /> Chlorination port available and sealed properly Yes ❑ No ❑ NA❑ <br /> SAMPLE TAP AND BACKFLOW PREVENTION: <br /> Non-threaded sample tap between well head and <br /> check valve or within 3' of well head Yes a No ElNA❑ <br /> Adequately installed check valve or BFP device Yes ElNo ❑ NA❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No ❑ NA❑ <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA❑ <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes 0 No ❑ NA❑ <br /> Well/Pump free from.excessive vegetation Yes 0 No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes 2 N'60 <br /> Permit drawing sufficient to locate well in future YesEZ No ❑ If'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes [W] No ❑ <br /> OTHER: <br /> Comments: - <br /> 0 �- � <br /> . <br /> NOr 1 1 <br /> Inspected By: Title: <br /> Received By: Date: <br />